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Blood Pressure and Breathing Exercises

Reduction in Blood Pressure can ocur with Inspirational Breathing Exercises

Resistance respiratory muscle training has recently been demonstrated to reduce the blood pressure in a population of people in their 50's with 4-5 years of hypertension which were being treated with medication.

Participants with metabolic syndrome were excluded. Patients in the unloaded breathing group inhaled deeply through the device with the inlet tube set just above the level of the fluid so the inspired air was humidifed but there was no added resistance. For the loaded breathing group, the water level was set to provide an inspiratory load of 20 cmH 0. The patients were instructed to adopt a breathing pattern with a controlled fow rate of about 200 ml/sec, an inspiratory time of 4 seconds, and a total respiratory time of 10 seconds. The paced breathing was frst practised using a metronome in the laboratory until it could be reliably performed without the metronome. Patients rested for 5 seconds after every 6 deep breaths. Training was performed at home for 30 minutes, twice a day, every day for 8 weeks. Patients in the control group were asked to continue with their normal daily life.

Compared to the control group, systolic and diastolic blood pressure decreased signifcantly with unloaded breathing by means of 7.0 mmHg (95% CI 5.5 to 8.5) and 13.5 mmHg (95% CI 11.3 to 15.7), respectively (laboratory measures). With loaded breathing, the reductions were greater at 18.8 mmHg (95% CI 16.1 to 21.5) and 8.6 mmHg (95% CI 6.8 to 10.4), respectively. The improvement in systolic blood pressure was 5.3 mmHg (95% CI 1.0 to 9.6) greater than with unloaded breathing. Heart rate declined by 8 beats/min (95% CI 6.5 to 10.3) with unloaded breathing, and 9 beats/min (95% CI 5.6 to 12.2) with loaded breathing.

A simple device was used whereby a water bottle with an inhalation mouthpiece and an air intake straw was used. The straw was 20cm deep inside the water to obtain the required resistance. Training duration was for 30 minutes per day.

The mechanism of action has been suggested to be improved sympathetic tone. It would also be interesting to hypothesis that the lateral expansion of the ribcage, through the engagement of the diaphragm, results in the drawing upward and outward the myofascia of the Psoas Major, taking some pressure off the deep abdominal blood vessels such as the vena cava.

The diaphragm is a large muscle, occupying a large area of the abdominal cavity, sitting immediately in front of the sympathetic soleus plexus and adjacent to the splanchnic arterial and venous system

Exercise and Age-Related Decline in Arterial Vasodilation

Ageing has been associated with reduced arterial vasodilation and hypertension. Elevation of free oxygen radicals are thought to inactivate Nitrous Oxide (NO). Using a severe hand-gripping model, Shoemaker et al (Am J Physiol, 1997; 273, H23488-95) were able to demonstrate 7% vasodilation in young subjects versus only 3% brachial vasodilation in older individuals. Anecdotal evidence supporting the use of oral antioxidant supplementation comes from Japanese, Scandinavian and Italian populations where a high incidence of centenarians has been associated with diet. However, the use of oral antioxidants alone, in the abscence of exercise, has not been shown to reduce the risk of cardiovascular disease. Paradoxically, administration of high levels of Vitamin C after exercise seem to reduce the vasodilatory effect of exercise, suggesting some positive 'down-stream'  effects of oxygen free radicals on cardiovascular health (Wry et al 2011, Exerc & Sp Sci Rev, 39, 2, 68-76). Alternatively, the chronic balance of oxygen free radicals and their complementary antioxidants may be more important, suggesting regular exercise and dietry function rather than extremes of either are more significant contributors to cardiovascular health. Investigations, using small muscle mass oxidative stress such as knee extension training, which have minimal central cardiovascular responses, have demonstrated positive cardiovascular effects on blood pressure function (Richardson et al 2004, Am J Resp Crit Care Med, 169, 1, 89-96; Shephard et al 1997, Sports Medicine, 23, 2, 75-92). Such findings are important in subjects with central cardiovascular compromise, but moreover have an impact on exercise adherence where subjects do not enjoy whole body high oxidative stress exercise. Furthermore, although blood pressure wasn't shown to be effected by acute antioxidant supplementation, the muscle perfusion post exercise was 30-40% greater in the older individuals receiving supplementation (Wry et al 2009, Clin Sci (Lond.), 116, 5, 433-41). Moreover, phosphate markers of post exercise skeletal muscle energetics suggests further positive benefits of antioxidant supplementation in older individuals (Wry et all 2011, Exerc & Sp Sci Rev, 39, 2, 68-76). Therefore, regardless of the reduction in perfusion during exercise, post exercise effects of antioxidant supplemenation and the known increased functional capacity of trained individuals suggest efficient physiological musculoskeletal compensation, to mitigate against the aging process.

At Back In Business Physiotherapy we have been recommending people commence using such a strategy as resistance breathing using Power Breath apparatus, to help improve peoples blood pressure problems. Furthermore, we have recommended it's use in clients with Low back Pain to improve diaphragmatic lateral expansion, core stability and the engagement of the pelvic floor muscles.

powerbreathe-main

Reference

Jones CU, Sangthong B, Pachirat O (2010) An inspiratory load enhances the antihypertensive effects of home-based training with slow deep breathing: a randomised trial. Journal of Physiotherapy 56: 179–186
 

Effect of inspiratory muscle training on exercise tolerance in asthmatic individuals.

Inspiratory muscle training has been shown to attenuate inspiratory muscle fatigue, reduces the perception of dyspnea, and increases exercise tolerance in people with mild to moderate asthma (FEV>70%). Training consisted of 30 inspiratory breaths, twice a day using a PowerBreathe device, at a pressure thtreshold 50 % of PImax, for 6 weeks. Turner et al (2011, Med Sci in Sp Ex, 43, 11, 2031-2038) findings included an increase in inspiratory muscle strength of 27%. Other investigations have demonstrated these results could be due to an increased thickness of the diaphragm as well as hypertrophy (Downey et al 2007 Resp Physiol Neurobiol, 156, 2, 137-146) of type I and type II external intercostal muscles (Ramirez-Sarmiento et al 2002, Am J Respir Crit Care Medicine, 166, 11, 1491-1497). Pulmonary function (FEV1 and FVC) weren't shown to change after 6 weeks of training, but have been shown to improve by 12% after 3-6 months of training amongst individuals with moderate to severe asthma (Weiner et al 2000, Chest, 117, 3, 722-727). Frequently, individuals with asthma have a reduction in exercise tolerance due to expiratory flow limitation and dynamic hyperinflation (EELV). The investigation by Turner et al (2011) demonstrated that this affect was attenuated at both the onset of exercise and during exercise, which likely explains the improved oxygen consumption seen in the inspiratory trained individuals. Deep inspiration amongst individuals with asthma commonly results in a 'latched state' of smooth muscle stiffness and bronchial constriction. In contrast, deep inhalation with a pressure loading seems to release the 'latched state' resulting in less bronchoconstriction (How et al 2009, Respir Physiol Neurobiol, 166, 3, 159-163).

Inspiratory muscle training (IMT) in people suffering from type 2 diabetes with inspiratory muscle weakness

It has been demonstrated that 29% of people with type 2 diabetes present with inspiratory muscle weakness. After 8 weeks of training it was shown that IMT significantly increases inpiratory muscle pressure by 118% and the inspiratory muscle endurance time by 495% (Correa et al 2011, 43, 7, 1135 - 1141). This result is particularly important as the sensation of perceived breathlessness can be a significant negating factor in peoples adherence to exercise. Since, exercise is such an important aspect of improving the morbidity of type 2 diabetes then training program design needs to consider IMT in their exericise prescription.

IMT has been shown to improve proprioception (sense of joint position) in people with low back pain

In a previous investigation it was shown that individuals with recurrent nonspecific low back pain (LBP) and healthy individuals breathing against an inspiratory load decrease their reliance on back proprioceptive signals in upright standing. Because individuals with LBP show greater susceptibility to diaphragm fatigue, it is reasonable to hypothesize that LBP, diaphragm dysfunction, and proprioceptive use may be interrelated. After 8 wk of high IMT, individuals with LBP showed an increased reliance on back proprioceptive signals during postural control and improved inspiratory muscle strength and severity of LBP, not seen after low IMT. Hence, IMT may facilitate the proprioceptive involvement of the trunk in postural control in individuals with LBP and thus might be a useful rehabilitation tool for these patients. (Lotte et al, Medicine & Science in Sports & Exercise:January 2015 - Volume 47 - Issue 1 - p 12–19)

Habituation of the early pain-sensitivity respiratory response in sustained pain.

 Kato et al (2001) Pain, 91, 57 - 63

 Respiratory rate appears to be habitually high in the chronic pain state (from 13.2Hz to 17.7Hz)

  • the pre Boetzinger brainstem complex appears to be the target for pro-nociception and anti-nociception input
  • this may be significant in terms of the scalene muscles and thoracic outlet syndrome, thoracic spine posture and mobility; or in the case of diaphragmatic breathing, the lumbothoracic stability and rhythm
  • additionally, alterations in sympathetic nervous system activity may be expected

 

Updated: 20 January 2015


 

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  • Thu 22 Dec 2016

    Ehlers Danlos Syndrome

    Is your child suffering Ehlers Danlos Syndrome? Hypermobile joints, frequent bruising, recurrent sprains and pains? Although a difficult manifestation to treat, physiotherapy can help. Joint Hypermobility Syndrome (JHS) When joint hypermobility coexists with arthralgias in >4 joints or other signs of connective tissue disorder (CTD), it is termed Joint Hypermobility Syndrome (JHS). This includes conditions such as Marfan's Syndrome and Ehlers-Danlos Syndrome and Osteogenesis imperfecta. These people are thought to have a higher proportion of type III to type I collagen, where type I collagen exhibits highly organised fibres resulting in high tensile strength, whereas type III collagen fibres are much more extensible, disorganised and occurring primarily in organs such as the gut, skin and blood vessels. The predominant presenting complaint is widespread pain lasting from a day to decades. Additional symptoms associated with joints, such as stiffness, 'feeling like a 90 year old', clicking, clunking, popping, subluxations, dislocations, instability, feeling that the joints are vulnerable, as well as symptoms affecting other tissue such as paraesthesia, tiredness, faintness, feeling unwell and suffering flu-like symptoms. Autonomic nervous system dysfunction in the form of 'dysautonomia' frequently occur. Broad paper like scars appear in the skin where wounds have healed. Other extra-articular manifestations include ocular ptosis, varicose veins, Raynauds phenomenon, neuropathies, tarsal and carpal tunnel syndrome, alterations in neuromuscular reflex action, development motor co-ordination delay (DCD), fibromyalgia, low bone density, anxiety and panic states and depression. Age, sex and gender play a role in presentaton as it appears more common in African and Asian females with a prevalence rate of between 5% and 25% . Despite this relatively high prevalence, JHS continues to be under-recognised, poorly understood and inadequately managed (Simmonds & Kerr, Manual Therapy, 2007, 12, 298-309). In my clinical experience, these people tend to move fast, rely on inertia for stability, have long muscles creating large degrees of freedom and potential kinetic energy, resembling ballistic 'floppies', and are either highly co-ordinated or clumsy. Stabilisation strategies consist of fast movements using large muscle groups. They tend to activities such as swimming, yoga, gymnastics, sprinting, strikers at soccer. Treatment has consisted of soft tissue techniques similar to those used in fibromyalgia, including but not limited to, dry needling, myofascial release and trigger point massage, kinesiotape, strapping for stability in sporting endeavours, pressure garment use such as SKINS, BSc, 2XU, venous stockings. Effectiveness of massage has been shown to be usefull in people suffering from chronic fatigue syndrome (Njjs et al 2006, Man Ther, 11, 187-91), a condition displaying several clinical similarities to people suffering from EDS-HT. Specific exercise regimes more attuned to co-ordination and stability (proprioception) than to excessive non-stabilising stretching. A multi-modal approach including muscle energy techniques, dry needling, mobilisations with movement (Mulligans), thoracic ring relocations (especially good with autonomic symptoms), hydrotherapy, herbal supplementaion such as Devils Claw, Cats Claw, Curcumin and Green Tee can all be useful in the management of this condition. Additionally, Arnica cream can also be used for bruising. Encouragment of non-weight bearing endurance activities such as swimming, and cycling to stimulate the endurance red muscle fibres over the ballistic white muscles fibres, since the latter are preferably used in this movement population. End of range movements are either avoided or done with care where stability is emphasized over mobility. People frequently complain of subluxation and dislocating knee caps and shoulders whilst undertaking a spectrum of activities from sleeping to sporting endeavours. A good friend of mine, Brazilian Physiotherapist and Researcher, Dr Abrahao Baptista, has used muscle electrical stimulation on knees and shoulders to retrain the brain to enhance muscular cortical representation which reduce the incidence of subluxations and dislocations. Abrahao wrote : "my daughter has a mild EDS III and used to dislocate her shoulder many times during sleeping.  I tried many alternatives with her, including strenghtening exercises and education to prevent bad postures before sleeping (e.g. positioning her arm over her head).  What we found to really help her was electrostimulation of the supraspinatus and posterior deltoid.  I followed the ideas of some works from Michael Ridding and others (Clinical Neurophysiology, 112, 1461-1469, 2001; Exp Brain Research, 143, 342-349 ,2002), which show that 30Hz electrostim, provoking mild muscle contractions for 45' leads to increased excitability of the muscle representation in the brain (at the primary motor cortex).  Stimulation of the supraspinatus and deltoid is an old technique to hemiplegic painful shoulder, but used with a little different parameters.  Previous studies showed that this type of stimulation increases brain excitability for 3 days, and so we used two times a week, for two weeks.  After that, her discolcations improved a lot.  It is important to note that, during stimulation, you have to clearly see the humerus head going up to the glenoid fossa" Surgery : The effect of surgical intervention has been shown to be favourable in only a limited percentage of patients (33.9% Rombaut et al 2011, Arch Phys Med Rehab, 92, 1106-1112). Three basic problems arise. First, tissues are less robust; Second, blood vessel fragility can cause technical problems in wound closure; Third, healing is often delayed and may remain incomplete.  Voluntary Posterior Shoulder Subluxation : Clinical Presentation A 27 year old male presented with a history of posterior shoulder weakness, characterised by severe fatigue and heaviness when 'working out' at the gym. His usual routine was one which involved sets of 15 repetitions, hence endurance oriented rather than power oriented. He described major problems when trying to execute bench presses and Japanese style push ups.  https://youtu.be/4rj-4TWogFU In a comprehensive review of 300 articles on shoulder instability, Heller et al. (Heller, K. D., J. Forst, R. Forst, and B. Cohen. Posterior dislocation of the shoulder: recommendations for a classification. Arch. Orthop. Trauma Surg. 113:228-231, 1994) concluded that posterior dislocation constitutes only 2.1% of all shoulder dislocations. The differential diagnosis in patients with posterior instability of the shoulder includes traumatic posterior instability, atraumatic posterior instability, voluntary posterior instability, and posterior instability associated with multidirectional instability. Laxity testing was performed with a posterior draw sign. The laxity was graded with a modified Hawkins scale : grade I, humeral head displacement that locks out beyond the glenoid rim; grade II, humeral displacement that is over the glenoid rim but is easily reducable; and grade III, humeral head displacement that locks out beyond the glenoid rim. This client had grade III laxity in both shoulders. A sulcus sign test was performed on both shoulders and graded to commonly accepted grading scales: grade I, a depression <1cm: grade 2, between 1.5 and 2cm; and grade 3, a depression > 2cm. The client had a grade 3 sulcus sign bilaterally regardless if the arm was in neutral or external rotation. The client met the criteria of Carter and Wilkinson for generalized liagmentous laxity by exhibiting hyperextension of both elbows > 10o, genu recurvatum of both knees > 19o, and the ability to touch his thumbto his forearm Headaches Jacome (1999, Cephalagia, 19, 791-796) reported that migraine headaches occured in 11/18 patients with EDS. Hakim et al (2004, Rheumatology, 43, 1194-1195) found 40% of 170 patients with EDS-HT/JHS had previously been diagnosed with migraine compared with 20% of the control population. in addition, the frequency of migraine attacks was 1.7 times increased and the headache related disability was 3.0 times greater in migraineurs with EDS-HT/JHS as compared to controls with migraine (Bendick et al 2011, Cephalgia, 31, 603-613). People suffering from soft tissue hypermobility, connective tissue disorder, Marfans Syndrome, and Ehler Danlos syndrome may be predisposed to upper cervical spine instability. Dural laxity, vascular irregularities and ligamentous laxity with or without Arnold Chiari Malformations may be accompanied by symptoms of intracranial hypotension, POTS (postural orthostatic tachycardia syndrome), dysautonomia, suboccipital "Coat Hanger" headaches (Martin & Neilson 2014 Headaches, September, 1403-1411). Scoliosis and spondylolisthesis occurs in 63% and 6-15% of patients with Marfans syndrome repsectively (Sponseller et al 1995, JBJS Am, 77, 867-876). These manifestations need to be borne in mind as not all upper cervical spine instabilities are the result of trauma. Clinically, serious neurological complications can arise in the presence of upper cervical spine instability, including a stroke or even death. Additionally, vertebral artery and even carotid artery dissections have been reported during and after chiropractic manipulation. Added caution may be needed after Whiplash type injuries. The clinician needs to be aware of this possibility in the presence of these symptoms, assess upper cervical joint hypermobility with manual therapy techniques and treat appropriately, including exercises to improve the control of musculature around the cervical and thoracic spine. Atlantoaxial instability can be diagnosed by flexion/extension X-rays or MRI's, but is best evaluated by using rotational 3D CT scanning. Surgical intervention is sometimes necessary. Temperomandibular Joint (TMJ) Disorders The prevelence of TMJ disorders have been reported to be as high as 80% in people with JHD (Kavucu et al 2006, Rheum Int., 26, 257-260). Joint clicking of the TMJ was 1.7 times more likely in JHD than in controls (Hirsch et al 2008, Eur J Oral Sci, 116, 525-539). Headaches associated with TMJ disorders tend to be in the temporal/masseter (side of head) region. TMJ issues increase in prevelence in the presence of both migraine and chronic daily headache (Goncalves et al 2011, Clin J Pain, 27, 611-615). I've treated a colleague who spontaneously dislocated her jaw whilst yawning at work one morning. stressful for me and her! Generally, people with JHD have increased jaw opening (>40mm from upper to lower incisors). Updated 18 May 2017  Read More
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Updated : 10 May 2014

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